1. Field of the Invention
This invention relates to new and useful improvements in breast surgery and more particularly to an endoscopic assisted mastopexy (breast elevation), including reduction mammoplasty (surgical removal of breast tissue) and mastopexy with prosthetic augmentation. The invention relates generally to a surgical procedure utilizing an endotube, obturator and/or other appropriate instruments, utilizing at least one small hidden incision, under the armpit, or in a preexisting scar, or other substantially unobservable locations.
2. Brief Description of the Prior Art and History of Breast Reduction Surgery
Mastopexy (surgical elevation of the breast and reduction mammoplasty (surgical removal of breast tissue) has been known and successfully carried out for many years.
The surgeon's quest for the ideal method of breast reduction began long before there was a specialty of plastic surgery. Many names associated with the reduction mammoplasties in the 1920's included Thorak, Morestin, Joseph, Dufourmentel, and de Quervain.
Dr. Biesenberger, in Biesenberger, H., Deformitaten and kosmetische operationen der weiblichen Brust. Vienna: Maudrich, 1931, described an extensive glandular resection with nipple transposition in which he did a very wide undermining of the skin with exposure of the gland. Certain variations of his technique are still used today with some plastic surgeons who agree fully with wide undermining and others who do not agree with wide undermining.
The gynecologists and general surgeons for many years learned and practiced their skills by making large incisions and under direct vision healing their patients. General surgery residents were taught that a skin incision heals from side to side, not end to end, therefore making all incisions as long as necessary. The reason for discussing and showing the techniques of doing the "open" circumareolar reduction mammoplasties, mastopexies, and mastopexies with augmentation, is because when surgery is done through the axilla, exactly the same work is done inside as has been done in the "open" circumareolar technique save for two factors.
Dr. Robert J. Wise, (Wise, R., A Preliminary Report of a Method of Planning the Mammoplasty. Plast. Reconstr. Surg. 17:367, 1956), working in Houston, Tex., had analyzed and come up with some of the earliest ideas, methods, and techniques to accomplish a reduction mammoplasty and obtain symmetrical results with excellent preservation of the nipple and skin and with free grafting of the nipple in large breasts.
Dr. J. Strombeck (Strombeck, J., Mammoplasty: Report of a new technique based on the two-pedicle procedure. Br. J. Plast. Surg. 13:79, 1960) reported on his new technique for breast reduction based on the two pedicle procedure.
Dr. T. Skoog (Skoog, T., A technique of breast reduction. Transposition of the nipple on a cutaneous vascular pedicle. Acta Chir. Scand, 126:453, 1963) reported on his new technique of breast reduction by transposition of the nipple on a continuous vascular pedicle and by 1967, Dr. I. Pitanguy (Pitanguy, L., Surgical treatment of breast hypertrophy. Br. J. Plast. Surg. 10: 78, 1967 ) reported on his technique of treatment of breast hypertrophy in an effort to give a better shape and better results postoperative.
Up to this point in the late 1960s the two primary considerations in doing the reduction mammoplasties were (1) do not have any necrosis of the skin or the nipple and (2) get an adequate reduction with as good a form as possible. No real consideration was being given to sensation in the nipple nor the ability of the nipple to lactate and function to nurse an infant should that become necessary.
Beginning in about 1973 Dr. L. Ribeiro (Ribeiro, L. A new technique for reduction Mammoplasty. Plast. Reconstr. Surg. 55:330, 1975) began doing reduction mammoplasties using an inferiorly based pedicle flap. He reported his work in March of 1975 and this was the first report of a new procedure that had a tremendous influence on the type of reductions that are done presently. Dr. Ribeiro's inferiorly based pedicle flap to preserve the nipple was also one of the first procedures designed in reduction mammoplasty that gave an excellent chance for preservation of sensation of the branches of both medial and lateral sensory nerves to the nipple as well as the possibility of lactation.
Then Dr. T. Robbin (Robbins, T. Reduction Mammoplasty with the Areolar-Nipple Based on an Inferior Pedicle. Plast. Reconstr. Surg. 59: 64, 1977) reported in 1977 of his experiences with a reduction mammoplasty with the areolar-nipple complex based on an inferior dermal pedicle. Dr. Robbins was especially aware that his technique meant that nipple sensation was more often retained than other methods of reduction.
The efforts of Dr. Ribeiro and Dr. Robbins in promoting the inferior pedicle technique was given a tremendous boost when in April of 1977, Dr. Courtiss and Dr. Goldwyn (Courtiss, E. and Goldwyn, R. Reduction mammoplasty by the inferior pedicle technique. Plast. Reconstr. Surg. 59: 500, 1977) published their article on reduction mammoplasty by the inferior pedicle technique. Dr. Courtiss and Goldwyn likewise found that the resulting breast sensation in their series of patients was better than obtained after other methods of reduction mammoplasty. They likewise found that the inferior pedicle technique was a versatile method for reduction for both large and small breasts and they found that any result that you could obtain by another method you could basically obtain with the inferior pedicle technique and complications were certainly no more, and probably less, than any other technique. They felt that with regard to the resulting nipple and areolar sensation that the inferior pedicle technique had the benefit of preserving the important cutaneous branches of the fourth, fifth, and frequently the third intercostal nerves. They stated that patients with normal sensations before surgery usually showed no change after the operation.
By the beginning of the 1980s, of the five primary goals of the patient and surgeon for breast reduction, the average plastic surgeon was now able to achieve either fully or partially four of these goals.
1. A breast of ideal size for the patient elevated to a normal position.
2. A breast of ideal form or shape for the patient.
3. A breast with normal sensation and erectile function of the nipple.
4. A breast that could lactate and could function normally in nursing.
Goldwyn's objectives modified by Haubin, see Finger, R. et al. Superiomedial Pedicle Technique of Reduction Mammoplasty. Discussion. Plast. Reconstr. Surg. 83: 471, 1989, for the optimal reduction mammoplasty are: safe, simple, speedy, sensation preserved, symmetry, suitably shaped and sexy breasts, and sine sanguine (bloodless) operation.
However, there still remained the problem of scarring and no one was yet able to eliminate the excessive scarring involved, especially with large reductions.
In the 1980s, the plastic surgeons began to turn their attention to reaching the further goal of the patient and surgeon, a breast with a minimal amount of scarring or minimal amount of visible scarring. Too many plastic surgeons for too many years have accepted scarring as an inevitable part of our profession. Elimination of scars is a most desirable goal to be reached.
Dr. S. Hoffman (Hoffman, S. Discussion. Elimination of the vertical scar in reduction mammoplasty. Plast. Reconstr. Surg. 89: 468, 1992) commented that it is hard to believe we are still inventing new procedures for breast reductions and he did accurately observe that many of the techniques are not really new and one would be amazed at how often a careful review of the older literature yields surprisingly new information.
With the dawn of increased interest in the elimination of the scars, or at least minimizing of the scars and making them less visible, Dr. G. Peixoto (Peixoto, G. Reduction mammoplasty: A personal technique. Plast. Reconstr. Surg 65: 217, 1980) reported a personal technique of his in the methods to reduce scarring.
Drs. C. Marachac and G. De Olarate (Marshac, C., and De Olarte, G. Reduction mammoplasty and correction of ptosis with a short inframammary scar. Plast. Reconstr. Surg. 69: 45, 1982) reported reduction mammoplasty and correction of ptosis with a short inframammary scar in 1982.
In 1986, Dr. E. DeLongis (DeLongis, E., Mammoplasty with an L-shaped limited scar and retropectoral dermopexy. Aesthetic Plast. Surg. 10: 171, 1986) reported a mammoplasty with an L-shaped limited scar and retropectoral dermopexy.
Dr. F. Marconi (Marconi, F. The dermal purse-string suture: A new technique for a short inframammary scar in reduction mammoplasty and dermal mastopexy. Ann. Plast. Surg. 22: 484, 1989) reported the use of a dermal purse-string suture and a new technique for short inframammary scar in reduction mammoplasty and dermomastopexy.
Dr. L. Benelli, in 1990, (Benelli, L. A new periareolar mammoplasty: The "Round Block" technique. Aesthetic Plast. Surg. 14: 93, 1990) reported a new technique for periareolar mammoplasty by what he described as the "round block" technique. Dr. Benelli has also continued to be very active in this field of reduced scarring and has been promoting this very actively.
Johnson U.S. Pat. No. 5,258,026 discloses a surgical procedure for breast augmentation in which an incision is made inside the navel or umbilicus. An endotube which has an obturator with a bullet shaped tip is introduced into this incision and pushed from the umbilicus, staying just above the fascia of the interior abdominal and chest wall, and below the subcutaneous tissue and fat, to a position behind the breast. The obturator is removed and an endoscope used to verify the proper location of the tunnel. The endotube is removed leaving a temporary tunnel leading to a space behind the breast. A hollow prosthesis is rolled up tightly, positioned inside the end of the endotube and pushed into the tunnel behind the beast. The prosthesis is held in place by the hand of the surgeon on the breast and the endotube removed. The prosthesis is pumped full of saline solution to about a 50% over-fill. The filling of the prosthesis with saline solution, together with the manipulation and pressure by the surgeon causes the tissues behind the breast to be dissected to form a pocket filled by the implant. After a short time, excess liquid is allowed to flow out of the prosthesis and the fill tube removed. The procedure is then repeated for the other breast. The navel is sutured and the patient may then go home from the recovery room.